Take a second and visualize an act of discrimination. Is this action explicit and rather overt in its nature and delivery? Implicit bias is its twin, but this bias is discriminatory and prejudiced behavior that flies undetected (mostly). Physicians and nurses may not even be aware that they are contributing to this perpetuating cycle of harm.
Since I know you may be wondering where these biases stem from and how they are caused, they are most certainly "unavoidable [and] acquired from the cultural atmosphere in which one is immersed daily. This cultural immersion includes literature, visual entertainment media, and audio and print news media and is also embossed in long-established practices of many public and private institutions" (Greenwald, A. G., et al., 2022). In other words, it is the obtaining of attitudes, beliefs, and/or stereotypes of a group or class of people which can ultimately influence physical evaluations and decision-making.
Taking a Deeper Look
A study of U.S. medical students showed that 48.7% reported that they had at one point or another been exposed to "negative comments about Black patients by attending or resident physicians, and those students demonstrated significantly greater implicit racial bias in year 4 that they had in year 1" (Sabin, J. A., 2022). A repeated misinterpretation is that good people cannot possibly possess implicit biases, and those who do must be innately bad people. This is not entirely the case as it is a deeply woven belief that may have been ingrained into the physician and/or nurses' attitudinal belief since childhood.
Sweden even tested this hypothesis by utilizing Arab-sounding names in place of Swedish-sounding names to determine if biases would erupt; the study ultimately concluded that there was a correlation between the HR professionals who preferred the CVs with Swedish-sounding names (FitzGerald, C., et al., 2017). This shows an elevated level of implicit bias towards Arabs. While this study did not directly correlate with the idea of implicit bias in healthcare, it is a notion that affects all, regardless of occupation or field.
A systematic review, or a review that looks at multiple studies to form a conclusion, concluded that almost all of the studies they had sifted through, indicated some implicit biases among physicians and nurses. The review took it one step further and used the available evidence to indicate which characteristics are the most at issue including "race/ethnicity, gender, socio-economic status (SES), age, mental illness, weight, having AIDS, brain-injured patients perceived to have contributed to their injury, intravenous drug users, disability, and social circumstances"(FitzGerald, C., et al., 2017).
All of the above characteristics include a large percentage of the general US population, considering the array of circumstances; this would mean the patient's quality of care and treatment is ultimately being affected. So, how would this manifest? The Joint Commission discusses how it would look on a case-by-case basis. It includes but is not limited to "Non-white patients [who] receive fewer cardiovascular interventions and fewer renal transplants, Black women are more likely to die after being diagnosed with breast cancer, Non-white patients are less likely to be prescribed pain medications" (Quick Safety Issue 23...). Again, this is just to name a few, there are many instances we see in healthcare where implicit bias weasels its way inside patient rooms.
How We Reform From Here
However, there are ways in which we can recognize, reprogram, and counteract these unconscious attitudes and belief systems. The University of California, for example, is developing a form of technology that will aid in addressing implicit bias in a clinical care setting. The technology itself would "detect nonverbal social signals that transmit clinician's implicit bias in real-time interactions with patients and provide feedback to the clinician or clinician-in-training" (Sabin, J. A., 2022). Simply creating this piece of technology is (unfortunately) not enough to rewrite systemic racism.
An article that included authors from various backgrounds i.e., MD, MPH, and PhD, looked at implicit bias and health disparities as a whole. Since the science and studies conducted on implicit bias is rather small, they suggested three goals in moving forward: "1) determine the degree of different implicit biases for different groups; 2) assess the associations among implicit bias and processes and outcomes of care; 3) test interventions to reduce implicit bias in health care and outcomes if bias is found to be important in health care" (Blair, I., V., 2011).
We must move forward in a way that is open-minded to the possibility that implicit bias may not be seen and may not be heard, but constitutes very real interactions on a day-to-day basis, in a lot of our own preferred inpatient and outpatient facilities.
References
1) Blair, I. V., Steiner, J. F., & Havranek, E. P. (2011). Unconscious (Implicit) Bias and Health Disparities: Where Do We Go From Here? The Permanente Journal, 15(2), 71-77.https://www.thepermanentejournal.org/doi/pdf/10.7812/TPP/11.979?download=true
2) FitzGerald, C., & Hurst, S. (2017, March 1). Implicit bias in healthcare professionals: A systematic review - BMS medical ethics. BioMed. https://bmcmedethics.biomedcentral.com/articles/10.1186/s12910-017-0179-8?report=reader
3) Greenwald, A. G., Dasgupta, N., Teachman, B. A., Dovidio, J. F., Kang, J., & Moss-Racusin, C. A. (2022, May 19). Implicit-bias remedies: Treating discriminatory bias as... SageJournals. https://journals.sagepub.com/doi/abs/10.1177/15291006211070781
4) Quick safety issue 23: Implicit bias in health care. The Joint Commission. (n.d.). https://www.jointcommission.org/resources/news-and-multimedia/newsletters/newsletters/quick-safety/quick-safety-issue-23-implicit-bias-in-health-care/
5) Sabin, J. A. (2022, July 14). Tackling implicit bias in health care | Nejm. The New England Journal of Medicine. https://www.nejm.org/doi/full/10.1056/NEJMp2201180